Thursday, December 31, 2009

"And now let us welcome the new year, full of things that have never been.”—Rainer Maria Rilke

Greetings,

It’s an exciting time to work in a safety net hospital. We are privileged to serve the residents of Contra Costa County and it is my privilege to work with all of you. This year Contra Costa Regional Medical (CCRMC) begins a three-year planned cycle of ongoing quality improvement using a number of new approaches. CCRMC has seen promising results in clinical system performance with our initial redesign efforts. We are now well into the next phase of system redesign and performance improvement using leadership systems and tools like ‘systems engineering’ and ‘lean management’ to accelerate the transformation of our health system.

Fulfillment of our mission is a dynamic and ongoing process. In order to “do common things uncommonly well,” we need objective information to support us. The heart of the work ahead must focus not only on science, but also on action. Quality must be at the heart of all operations. Our efforts must be directed toward specific areas of work to assure no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one is left out.

Currently, health care makes up about 17% of our nation's gross domestic product (GDP) and is climbing at a steady and unsustainable rate. In America, we hear daily debates about bailouts, stimulus packages and health reform. Although the solutions are still in the development phase, it’s clear we will change course nationally and we must do the same here at the local level. Our mission is being challenged by the current economic downturn. The number of people who are struggling to meet their most basic needs is increasing in our community. It’s during these difficult times when safety net hospitals are called on to stretch already tight resources making quality, evidence-based practice, teamwork and communication the keys to success.

The debate will continue in our nation’s capital about what reform legislation will look like. Yet it is here, at the local level, that the actual impact of health reform will be determined. Just as an individual's experience of our system is determined at the point of care delivery and not in a conference room, health reform will be realized at the local level, not far away in the halls of Congress.

Together, in partnership with those we serve, we will continue to provide quality care to all people in Contra Costa County with special attention to those who are most vulnerable to health problems. We recognize and stand ready to embrace our responsibility to engage as active members of America’s Health Care Safety Net and as participants in the nation’s movement toward health for all.

Tuesday, December 22, 2009

Remembering my Dad on his birthday...

Striking a balance between between celebration and acceleration.

Recently, I've been thinking a great deal about pacing. When I recall CCRMC's efforts with System Redesign which began in 2005, I remember many of the crucial lessons learned from our participation in the IHI 100k lives Campaign. One year ago today I wrote about our redesign efforts and again today my thoughts drift to System Redesign, an important anchor in our transformation efforts.

Although System Redesign is no longer a group, rather a set of coordinated efforts aimed at transforming our system for the better, the lessons learned remain with us. We learned to challenge the status quo by centering our efforts on real time observation and proven science. We learned that although we are very similar to others and can adopt proven strategies from them, in general, local adaptation based on our unique culture remains essential to realize meaningful and enduring change. We learned how important it is to not only involve, but to tirelessly support, those on the front line being actively engaged in design and improvement teams. We learned you cannot improve that which you cannot measure. By listening to patients and families, we learned how much we don't know. We learned what we thought was important to those we serve was not always the same as what was really important to those we serve. We learned the importance of shared vision and aims. Did I say anything about measurement? I know I already stressed measurement, but I thought I would throw it in once more for good measure! We learned how important it is to acknowledge and celebrate all efforts - even what seems the smallest accomplishments - and to accelerate our efforts to assure no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left out. Celebration and acceleration, do you remember?

Like so many of you, I too am eager for a new day. I still haven't come to any definitive position on pacing other than action is needed for change. I acknowledge "soon is not a time." However, I do believe that big change begins with a bold aim and a small test. It starts with us, transforming our system, one test at a time.

Recently, I've been thinking a great deal about pacing. When I recall CCRMC's efforts with System Redesign which began in 2005, I remember many of the crucial lessons learned from our participation in the IHI 100k lives Campaign. One year ago today I wrote about our redesign efforts and again today my thoughts drift to System Redesign, an important anchor in our transformation efforts.

Although System Redesign is no longer a group, but rather a set of coordinated efforts aimed at transforming our system for the better, the lessons learned remain with us. We learned to challenge the status quo by centering our efforts on real time observation and proven science. We learned that although we are very similar to others and can adopt proven strategies from them, in general, local adaptation based on our unique culture remains essential to realize and embed real and enduring change. We learned how important it is to not only involve, but to tirelessly support, those on the front line being actively engaged in design and improvement teams. We learned you cannot improve that which you cannot measure. By listening to patients and families, we learned how much we don't know. We learned what we thought was important to those we serve was not always the same as what was really important to them. We learned the importance of shared vision and aims. Did I say anything about measurement? I know I did but I thought I would throw that in for good measure! We learned how important it is not only to acknowledge and celebrate all efforts even what seems the smallest accomplishments, but also to accelerate our efforts to assure no needless pain or suffering, no helplessness in those served or serving, no unwanted waiting, no waste and no one left behind. Celebration and acceleration, do you remember?

Like so many of you, I too am eager for a new day - hence, my original question about pacing. How big do we design and how fast do we go? If I draw from the original lessons learned I would look to real time observations and proven science. What would Deming say if we could ask him? It is well documented that he did believe and teach that all transformation begins with the indvidual. Many of the tests we designed began with one patient, one doctor, one nurse, one day, one shift, one time...you get the idea. You can learn more about the Model For Improvement and how we at CCRMC have used it in our improvement efforts here.

Saturday, December 19, 2009

I was looking at the work done by those tackling other social issues that are, in fact, our issues as well.

Note: By his courage to relentlessly pursue what he believes in, Joe McCannon, Vice President at the Institute for Healthcare Improvement (IHI), inspires me to challenge my own thinking. It's just so easy to find safety and comfort "inside the box" isn't it?

Here is a link to the 10 year plan to end chronic homelessness in our communities, published by United States Interagency Council on Homelessness. I find the diffuse leadership structure of particular interest. In addition, the "Cost Implications" (#5) seem very familiar.

The video below focuses on homelessness in California, specifically Ventura County. Unfortunately, Contra Costa County looks no better. Each year, an estimated 15,000 people experience homelessness in our County, and on any given night, more than 4,800 people are homeless. 23,861 calls were received by the Hotline last year from homeless families and individuals seeking shelter in our communities. You can find the link to Contra Costa County Homeless Services here.

Tuesday, December 15, 2009

In a call to action, Tim Brown, CEO of the Global Design and Innovation Consultancy IDEO, asks if we could shift our thinking from having more to being more*.A curious question don't you think?

He further asks if this question only has relevance to those who "already have lots?"

We don’t have to look far to see possible applications of this thinking all around us. Rather than look for more resources, what if we could get more productivity out of the resources we already have? This is very much aligned with Lean thinking and supports engagement in process redesign. The principle of accomplishing more with the same amount of resources or inputs (simpler still, be of more value with less), or thinking leaner, has been well accepted. Yet if it's such an easy concept, why is change so slow and so difficult? Why do we have experts - whole departments in some cases - dedicated to leading change? The answer may be a bit more personal than we like. What if we are part of the problem? Could this be why W. Edwards Deming and Taiichi Ohno (大野 耐) stressed that in order to make real change we must first change ourselves? They said - and they are well supported by many others - that all change begins with the individual. More explicitly, all change starts with me/you.

Recently, I gave a talk with my esteemed colleagues Dr Jason Leitch and Dr Peter Lachman on transformation. We presented a common theory, The Model for Improvement. We then provided three distinct examples of the application of our theory in transformation efforts taking place on very different scales: a hospital, a county, and a country. The take-home message was that all change, no matter how big or small, occurs at the point of the individual experience. In short, no matter how many policies or change events you engage in, if it doesn't result in a change at the point of the actual experience you are trying to alter (in this case at the point of care), it isn't change, it's simply activity. In order to determine if the change you are making is in fact an improvement, you must have a measurement method (measurement is a topic for another post altogether.) My point is that the examples we presented support the idea that all change, whether on a single unit or spanning a nation, begins with changing me/you.

Let's think about the idea that we as individuals are the target of change. In your setting, who is it that is most likely to NOT let go of what they have? Looking at it another way, who is deriving power or authority in your environment/context from institutional inertia - commonly known as the status quo? Whose identity is coupled with mastery of the current state? Are they likely to give it up? I'm not targeting any particular person or group. I'm simply asking. Who do you think is open to change and who is least likely to really change (the haves or have-nots)? This can get particularly stinky if one can siphon off the new and exciting parts of an innovation/new thing AND keep what they already have. Where do I/you fall?

Marshall Ganz...First let me say I just saw him speak at the IHI National Forum (my favorite event of the year) and he was inspirational, frankly he was downright moving. I found his plenary address so much more than a speech. Were you there? Did you hear it? He refers to movements and feeling a calling. He speaks not of having more but of being more.

On the uncertainty of change and the pull of the status quo - the safety and comfort of what we know - he writes the following:

"When we face uncertainty, we often feel conflicting emotions. On the one hand, we may be fearful - things will go wrong, we will fail, others will see. We then retract, metaphorically at least, to protect ourselves from danger. On the other hand, we may be curious - the unexpected can be exciting, bring new opportunities and new growth. So faced with the challenge of learning to act in new ways, we may retreat into the security what we know, or, at least, what will reduce our anxiety; or we may risk leaning into the uncertain. We may learn best when we can do both: secure ourselves in enough certainty that we have the courage to risk exploration. Learning to balance security and risk is not only key to our own learning, but to the learning of those with whom we work, for whom security may be more elusive and the risks greater."

I understand and believe that change is scary. Many will retreat. Our perception of ourselves, whom we believe others approve of and depend on, is often that which we spend most of our time being. But what about our dreams? I know this sounds like a bit of starry-eyed psycho-babble, but what if we try and see ourselves as what or who we really want to be? Better yet, what if we could be that which we are capable of? Do we even know what that is? What if everything we think we are supposed to be were washed away? Dr. Robert Schuller asks, "What would you attempt to do if you knew you would not fail?" What would I do? I'll admit I don't have the answer. I have many questions. Is what I do based on being something or having something? Do I seek knowledge or mastery of the current state in order to understand how to change it fundamentally for the better? Or do I seek understanding of the current state in order to better know how I can achieve rewards from it? Aren't these awful questions? Is it possible I choose superficial success, such as having more because it's too scary to try and be more? Is it possible that the barriers I impose on myself serve a very important purpose: protection from the risk of failing or experiencing pain?

For today that's enough of what Tim Brown describes as "head-hurting thinking." If the answer/convergence of ideas is to come, it will only be through synthesis of all those divergent ideas and belief systems surrounding what it means to move beyond "having more" to actually "being more." Who knows, maybe having a little fun is part of it? I already confessed I had no answers. I only have starry eyes filled with hope.

Wednesday, December 9, 2009

With his permission I am posting a short essay written by my esteemed colleague Dr. Jon Stanger. I asked him to reflect on his experience at our last Kaizen report out.

I deeply respect Jon's perspective and hope you enjoy his comments as much as I did.

Anna

The following is his response:

Golfing With Friends Jon Stanger(Dr. Stanger is clinical and organizational ethics consultant at CCRMC. He is a member of the hospital Operations Team. His passions include family, medicine, literature, moral philosophy, and – recently – golf.)

We’ve all heard the expression, “A bad day on the golf course beats a good day at work.” Who’s going to argue? It’s not so much that I disagree but, in the wisdom of my maturity (i.e. as I get older), increasingly I find that experience has an irksome way of challenging categorical pronouncements. Here’s the deal. Somehow, one day last week I canceled a golfing date with good friends to attend a meeting at the hospital – and came out feeling, well, OK about it. This requires some explanation.

I successfully resisted golf for years. Even though advancing age and receding cartilage made it a natural for this erstwhile sportsman, I thought Mark Twain pretty much had it right when he described a day on the links as “a good walk spoiled.” Anyone with that much time on his hands needs to get a life. Besides, it’s not a real sport, is it? And “the physician golfing” calls to mind all the wrong associations – of plaid pants, power politics, and privilege – for this affirmed county doc.

About a year ago, trusted friends lured me onto the fairways for my first time. Start-up can be a painful experience for the novice. We can all remember our first times, right? Talk about performance anxiety. It takes a special mix of courage and humility to step up to that first tee, a gallery of aficionados on the clubhouse veranda feigning indifference while in fact watching you … judging you … smirking at you behind a foamy veil of Bud Light. That drive off the first tee is one of those rare certainties in life. You can be pretty much certain that it will be every bit as humiliating as you had imagined. Then, safely down the fairway at last, the searing pain of ego laceration gives way to a dull throb of frustration. This is when you realize the marketing genius behind the exorbitant green fees you just paid. Only such substantial investment, combined with primordial arrogance, keeps you from taking the shortest path from the fairway bunker directly back to the parking lot.

I have to believe that none but the delirious and demented would make it past the clubhouse turn of that first round were it not for a mysterious seduction that takes hold around the sixth or seventh holes. Stirring poetry has been (or should be) written about the power of that moment when the golfer, looking up from the Swoosh™ for the first time, finds herself painted onto a canvas of natural beauty and transcends preoccupation with her own situated particularity to embrace oneness with the cosmic universal. [Note: Italics here are employed to denote the author’s erudite use of technical philosophical terminology.] And there is something more I never anticipated – some alchemy of four friends, now comfortably distant from adolescent preoccupations with “winning,” sharing the disappointment of the slice into the woods along with the joy of the forty-foot chip that improbably finds the hole.

Certainly, golf has the challenge of personal improvement, and old-fashioned competitive drive has its place, but for me the appeal of golf is ineluctably social – friends come together for these few hours in a common pursuit, supporting each other, calling one another to the twin virtues of humility and courage as circumstances and individual dispositions require. We are in this together. We have learned together from the misadventures and triumphs of the last hole. Now the next tee is waiting, and beyond that another before we take our turn on the veranda to sip our beers and critique the next foursome. Stories will be squared, sins will be forgiven, hope renewed, fellowship affirmed, and a tee time booked for next week.

Where was I? Oh yes, last week I had a golfing date scheduled with good friends. Unfortunately, a conflict had arisen with work. On this same day there was to be a “reporting out” of a “kaizen event” that had been under way over the past week. I was not so isolated in my semi-retirement as to have no inkling what this involved. Kaizen is all the rage within hospital management circles these days, and my work in the field of organizational ethics requires that I have some basic understanding of these sorts of things. I had read the required texts, attended a few lectures.

The word “kaizen” is from the Japanese, meaning “improvement.” In common usage today it refers to a philosophy and practice of continuous improvement in the workplace. Pioneered in the Toyota production line, kaizen has gained popularity in a wide range of manufacturing, business, and, more recently, healthcare settings. A “kaizen event,” then, is a weeklong multi-disciplinary effort focused on improvement in a particular area of service. Surgical care had been the focus for this week’s event.

I confess to having cultivated a degree of skepticism toward this whole kaizen thing. From an ethics perspective, medicine is, or should be, the most teleological of disciplines. This means that the health professional must have a single-minded devotion to the end or purpose or “telos” of providing quality care for the vulnerable patient. To my view, many of the sins of medicine today can be laid at the feet of those who would betray this orthodoxy for the false idol of marketplace economics. Should we really be looking to Toyota Corporation for enlightenment? In this all-too-competitive world of health care qua market commodity, where efficiency has become the salient virtue, the last thing we need is for our administrators, let alone our clinicians, to be flitting across the continent from conference to conference genuflecting at the altar of business school dogma.

I knew that our organization was in the midst of just such a conversion. My reservations notwithstanding, the spread of this heresy within our hospitals and clinics is plainly evident in the new hallway vernacular of kaizen novitiates. “Lean”, “hansei”, “5 Whys”, “value stream mapping”, TPS, CQI, TCAB, TWI … Do you speak Kaizen? Do you have your Six Sigma black belt?

This was not the first time that the conference room had been invaded for a kaizen event. I had stolen glimpses of friends, colleagues, and fellow employees – physicians, nurses, clerks, administrators, housekeepers, pharmacists – all gathered together, cooing and pecking like a flock of pigeons in the park on a spring afternoon, before winging off to the wards at the behest of some unseen external threat. Surely, I was missing something. This had none of the feel of the muscular command and control management that we needed in these tough times. I mean who was in charge here? Who was calling the shots? Who was making the tough decisions? Just when we most needed an eagle, we had a flock of pigeons.

It was time I learned a little more about this whole undertaking. I was just plain curious, and the word itself – kaizen – seemed to suggest a spiritual imperative that could be ignored only at risk of soul damage. I also felt some responsibility, as organizational ethics consultant and a member of the operations team, to better understand the kaizen phenomenon. Besides, the morning broke cold and drizzly, so I called my buddies to say that I couldn’t make it for our golfing date.

I found a spot standing against a wall in the back of the conference room near the exit, ready for a quiet getaway. What followed was quite unlike any hospital meeting I had experienced, and I am a veteran of thousands. The executive sponsor gave a one-minute – really, one minute – welcoming statement of support for the activities of the past week. The balance of the session consisted of fifteen individual reports from various participants in the event. Each report was brief, perhaps two to three minutes long, and each told a story. Some of the reports addressed seemingly minor, though not unimportant, issues. “The FAX to Nowhere”, for instance, told of how a simple hardware cable connection lay at the root of a longstanding delay in getting post-op medications from the pharmacy. Other reports dealt with major systems issues such as reduction of surgical suite “turnover time” and elimination of a long waiting list for routine surgical cases.

The narrative structure of the reports was unmistakable: the protagonist of each story is the patient and the story is told from the perspective of the patient’s experience; a problem area or “conflict” is identified; paths to potential resolution of the conflict are tried; and the outcomes, good and not so good, are described. It may be that this narrative structure was unintentional on the part of the kaizen participants, but the effects are important nonetheless. Narrative ethics is one of the most exciting and productive areas of inquiry in the fields of both clinical and organizational ethics today. At the heart of this model are the observations that we humans are meaning-seeking and meaning-forming creatures, and that story is our most effective and engaging means of communicating meaning. Just as four duffers come to understand the day’s events on the golf course in terms of the stories they rehearse on the veranda, we shape and share the meanings attached to our professional work through narrative.

The narrative frame for our discussions of problems within the hospital, then, goes a long way toward determining the solutions we will imagine. It really is important that the stories told by the kaizen folks keep the patient’s point of view center stage and that frontline hospital workers are given roles as active agents for change within these stories. All too often the narratives we have customarily told under the rubric of performance improvement have been told from the perspective of the hospital, or the county budget, or the clinical department, or the employee. And all too often the casting call for agents of change has been limited to the pool of “stars” within the administrative and clinical hierarchy.

I was told that, during the week of this kaizen event, roughly one hundred empirical trials (“small tests of change”) had been implemented and that seventy-five of these were “successful.” To one who cut his teeth on a system in which a single change could take months to wend its way through the web of departmental and committee structures, often only to become terminally stuck, this seemed frankly unbelievable. The “trick” seemed to lie in a radical understanding of what is meant by “success” and a somewhat disarming comfort with giving new ideas a try. For the kaizen participants, success is always tentative. A change is not proven once and for all, engraved in the policies and procedures manual, and revisited again five years hence. There is no pretense to Ultimate Truth here. Rather, a new procedure is “standard” only until such time as an alternative approach is shown to be an improvement in meeting the ultimate goal of providing quality care for the patient.

So, there I was, against the wall, listening to this rather remarkable string of testimonials and thinking – thinking about medicine … and golf. As an affirmed intellectual, I need to read books and listen to experts when approaching any new discipline. This compulsion has lead me to pour over several golf texts authored by past masters of the game and to waste more than a few hours watching “tips from the pros” on the golf channel. I’ve learned that there are moments in the game that call for daring and panache, but the best results usually result from a steady routine, incremental improvement, and playing the percentages. Error and misadventure are inevitable and even the best of players must wrestle with the chimera of perfection. But this reality cannot excuse an, “Oh well, stuff happens,” attitude. It demands instead a discipline of error identification and management, and a commitment to incremental improvement so as to reduce the likelihood of repeating mistakes. There are breakthrough moments in golf … and in delivery of medical services … but improvement is mostly incremental, measured from season to season, the result of a disciplined dialectic of praxis and critical reflection. [More sophisticated ethics vocabulary.]

I have to say, however, that what struck me most about the kaizen report had little to do with tangible improvements in services. The stated goal of SCIP (“Surgical Care Improvement Project”) is a 25% reduction in surgical complications for certain target areas by the year 2010. That is nothing to scoff at, even if a one-week trial can’t be long enough to know whether changes have truly improved care. (Except maybe for that FAX cable.) But what really grabbed my attention was something about the demeanor of the people in the room. Call it enthusiasm … or engagement. It’s not easily labeled or measured, but there was a tangible sense of empowerment, purpose, collegiality, and community the likes of which I hadn’t felt in any committee meeting in recent memory.

My pigeon metaphor was off target. These weren’t doves, indistinguishable in the flock, driven by rote instinct and fear of external threats. A comparison to dolphins might be more appropriate. I don’t know a lot about dolphins, but they’ve always struck me as intelligent, inquisitive creatures, engaged in actively exploring their environment, each celebrating the freedom of its individuality yet always true to its social nature. Like our marine brethren, the kaizen folks behaved like empowered individuals united by a shared purpose and bound to one another by mutual respect.

And as for leadership, forget that eagle, alone and majestic on his rocky crag. A kaizen vision of leadership requires a humbler sort of majesty, wise but down to earth. Think owl or even turkey. This is the leader as sponsor, process expert, cheerleader and champion of the telos, less directive and more willing to trust and nurture employees’ shared commitment to the purpose that called them to this work.

Speaking of cheerleaders, I will own that the kaizen report felt a little like … well, a little like a high school pep rally. There was some applause and, at one point, I actually witnessed a high-five. I can see the eyebrows of my weathered colleagues rising at even the suggestion of such mawkish proceedings. But have we really become so cynical as to discredit an honest expression of enthusiasm resulting from an experience of working closely with colleagues to make things better for our patients? The feeling in the room was infectious. I found myself a little self-conscious, but also inspired – inspired and proud to call this group of dedicated professionals my friends and colleagues. Perhaps this is part of what organizational development experts mean when they say that the kaizen process can be “humanizing.”

Much of ethics boils down to theories of human nature. I side with those philosophers who argue that we humans fundamentally crave two things – meaning and community. It follows that the “good life” entails fulfillment of our nature through work that has an identified purpose greater than our own self-interest – work undertaken with our fellows in a spirit of radical respect for one another. This formula holds true throughout the range of human activities, whether building cars or caring for the sick … or golfing.

I’m not sure that I can yet be counted amongst the kaizen faithful. I will retain a certain measure of what I consider prudent skepticism regarding management models imported from the business world. And as a colleague cautioned, “We shouldn’t be too quick to drink the Kool-Aid.” But I also don’t want my concerns to make me too timid about stepping up to that first tee. For some time now, we who work in hospitals and clinics have been too disconnected from the ideal of service that called us to our profession. We have been too disconnected from each other. I don’t know if kaizen and similar recent performance improvement initiatives are the answer. What I do know is that on that morning last week there was something positive going on in the hospital conference room. It was new, and different, and a little threatening. But actually – and now I’m speaking from my expertise as an organizational ethics consultant – in some ways it was a lot like golfing with friends.